Whiplash injury

Mechanism of injury

Caused by what

Nonvoluntary acceleration and deceleration of the head and neck.

MVA, tackled from behind during football tackle

Whiplash injuries 

1) structures affected during extension

2) structures affected during flexion

1) Muscles: SCM, SCalenes, longus coli and longus capitis [stretched]

Facet joint irration, Ant. longitudinal ligment, spinous process.

2) sub occipitals, ant. compression of vertabraes, disc hernation, chin and sternum

80% of MVA patients reporting symptoms will have resolution of those symptoms in 3-4 weeks.

True or False

How long do Symptoms last

1) head on collision

2) impact from the side

3) hit from the rear 

1) no prolonged symptoms

2) no symptoms lasting longer than a few months

3) 50% still symptomatic after 1 year

1st stage of Whiplash treatment

[3]

1) Increased imphasis on education

2) if hypomobile a collar should be used to reduce stress on injured tissues.

3) Exercises are limited to AROM [proprioception, and static postural cueing]

2nd stage of whiplash treatment

[3]

1) Mobilizations

2) Specific HEP for stretching

3) postural awareness training in dynamic situations

3rd stage of treatment for whiplash

[2]

1) stabilization training for neuro re-ed

2) dynamic postural training incorporated with UE

Cervical Disc injuries

Mechanisum

Subjective findings

Traumatic injury in forward flexed position

Pain is the worst in the morning with or without referred/radicular symptoms.

Treatment of cervical Disc injury 1st stage

[4]

1) bracing if hypermobile

2) manual traction grade I-II

3) Gental small amplitude AROM

4) breathing exercises

1) postural correction; static

2) Address hypomobility with mobilization

Cervical disc injury treatment stage 3

[3]

1) incorporation of stretches/ soft tissue mobilization or neurovascular strutural interfaces when necessary

2) dynamic stabilization

3) postural awareness education for entire trunk

Postoperative management with anterior spinal fusion treatment plan.

What are disabilities that you could find?

[3]

Treat according to healing times and residual impairments.

1)decreased postural awareness 2) over compensation of accessory brathing muscles 3)hypomobility at select segments and decreased neuroomuscular control/strength/endurance

Chronic Cervical Tension Myalgia

Mechanism of injury

[4]

1) emotional tension

2) Chronic postural changes

3) Secondary to direct trauma

4) Most common finding forward head posture

1) intracranial sources such as HTN

2) head injury

3) intracranial tumor

4) cerebral hypoxia

Treatment of head aches progression

[5]

1)sepecific soft tissue/ myofacial techniques (suboccipitals and Levator Scapulae)

2) joint mobilization at restricted joints

3) neuromuscular re-ed for deep flexors and extensors

4) Postural training static and dynamic situations

5) pressure points @ occular orbit, zygomatic arch, 

Vertical Compression Test (C-Spine)

1) Testing for what

2) pt. position

3) Therapist 

4) technique

5) idications for positive test

1) Functional assessment of postural stability

2)Sitting

3) Standing behind the pt. with hands on the crown of the head.

4) apply vertical pressure down through the shoulders

5) breaking of postural stability

1) posterior elements of C-spine

2) Sitting in a chair

3) move the neck into extension, side bending and rotation to one side.

4)apply a vertical copression to the head

5) Radiating pain into the arm on the side that the head is bent to.

1) posterior elements of the C-spine

2) sitting

3) move the neck into extension and rotation to one side

4) apply parallel forces to the maxilla and scapula

5) reproduction of neurologic signs/symptoms and increased scapular pain.

1) subluxation of the atlas on the axis

2) sitting

3) one hand on forhead and the other hand on spinous process of C2

4) patient is asked to flex there neck while the therapist resists through contact with the forehead.

5) head slides posterior during movement

1) assess verterbral artery function

2)supine on plinth with head hanging over the table

3) therapist supports the patient's head with both hands

4)head and neck into maximal extension, side bending and rotation to the same side. This position is held for 30 sec. looking for nystagmus, dizziness, diaphoresis, nausea, pupillary changes.

5) if any of the above signs occurs

1) thoracic outlet syndrome [ant. and middle scalne entrapment]

2) standing or sitting

3) Locate the radial pulse

4) head is rotated towards test side. Pt. extends the neck while therapist ER and extends pt's shoulder. Pt. takes deep breath and holds it.

5) Dissappearance of the pulse

1) Thoracic outlet syndrome [clavical and 1st rib]

2) standing

3) radial pulse while standing at the side to be tested

4) Drawn down and back [ER and depress scap]

5) absence of pulse

*good test if pt. reports symptoms with wearing a back pack.

1) thoracic outlet syndrome

2) sitting

3) palpate the radial pulse

4) hyperabducts the arm with elbow and hand in the coronal plane, shoulder ER

5) absence of pulse

1) descent of the first rib is restricted or if the first rib is elevated.

2) supine

3) right hand: cups the upper cervical spine and occiput

Left hand: post to clavical, lateral to C7 transverse process and anterior to spine of scap.

4) pt. takes deep breath therapist allows for the deep breath and follows the rib downward as the patient breathes out and then holds the rib down

Upper thoracic Rotation in prone lying via the spinous process

1) Testing for what

2) pt. position

3) Therapist 

4) technique

1) increasing movment here will help reduce stress on the cervical spine, help gate pain, enable improved posture.

2) prone with head turned in teh direction to be manipulated.

3) right thumb: placed on teh right side of the more cephalic spinous process.

Left thumb: left side of the more caudal spinous process

4) series of 3 or 4 strong pressures to both thumb simultaneously.

Upper thoracic upslide in prone lying

1) Testing for what

2) pt. position

3) Therapist 

4) technique

1) increase rotation and side bending to the opposite side and forward bending.

2) neck slightly flexed

3) left thumb makes contact with the transverse process of the vertebrae to be manipulated, right thumb sits on top of left thumb

4) graded oscillations delivered by the right forearm and thumb through the relaxed left thumb

Upper thoracic and mid cervical central P-A mob (C-Spine)

1) Testing for what

2) pt. position

3) Therapist 

4) technique

1) general technique which will aid with all movements of the mid cervical and upper thoracic spine.

2) prone with spine in neutral

3) therapist stands so that the tips of their thumbs are in contact with the spinous processes.

4) therapist then exerts a P-A pressure through their thumb contact.

Upper thoracic and mid cervical unilateral P - A mob

1) Testing for what

2) pt. position

3) Therapist 

4) technique

1) general technique used to aid in all movements of the mid cervical and thoracic spine.

2) prone with neck in neutral

3) contacts the transverse process of vertebrae to be mobilized with tips of their thumbs

4) P-A pressure through their thumbs that is perpendicular to the plane of the joint.

Mid cervical upslide in prone (C-Spine)

1) Testing for what

2) pt. position

3) Therapist 

4) technique

5) Cautions

1) forward bending and rotation and side bending to the opposite direction.

2) neck slightly flexed and rotated towards the opposite side of the contact.

3) cephalid thumb is placed on teh articular process fo the vertebrae to be mobilized. more caudal thumb is placed on the 1st thumb

4) graded oscillations in the plane of the cervical facets

5) Do not do C3 and higher due to vertebral Artery compromise.

1) manubriosternal

2) sternocostal

3)interchondral

4) costotransverse

5) costovertebral

Ribs 1-6

 anteroposterior

Elevation of the rib cage is made by what motion of the rib neck?

Depression of the of the rib cage is made by what motion of the rib neck?

Upward rotation

Downward rotation

7-10

lateral

8-12

Lateral

What are the structures that help support the thoracic cavity?

[3]

Core musculature

extensive ligamentous support

sterno-costo-vertebral ring

Thoracic deformities

[6]

scoliosis

gibbus

dowager's hump

pectus carinatum

pectus excavatum

barrel chest

Hypomobility with or without pain

1) essential objective finding

2) tissues involved

3)cause

4) onset

5) location of the pain

6) where will the pain radate to

1) decreased osteokinematics motion

2) articular, myofascial or both

3) result of excessive bending or rotational force

4) insidious or sudden

5) can be on teh other side

6) can radiate to the anterior aspect

Hypermobility with or without pain

1) main objective finding

2) Caused by what

3) onset

4) area of pain

1) increased osteokinematics

2) acute major trauma, repetitive micro trauma

3) insidious or sudden

4) poorly localized/pain can radiate around the chest

A/P Rib Compression

1) use

2) pt. position

3) PT

4) Techniques

5) positive test

1) rib fracture and/or subluxation

2) seated or standing

3) one hand on the anterior chest while the other hand is on the ipsilateral posterior chest

4) Compression of chest wall

5) reproduction of pt. symptoms

1)rib fracture or subluxation

2) seated/ standing

3) standing behind pt. with hands on either side of the thorax

4) compress the thorax in a M/L dimention

5) reproduction of symptoms

1) Assesment of active costovertebral joint movement

2) sitting

3) standing with flexible tape measurer in hand

4) M1: Meaure 4th intercostal space w/ maximal exhale and inhale

M2: meausre under axilla, nipple line and T10 @ max exhale and inhale

5) normal inspiration and expiration difference is 1-3 inches.

1) Assesment of sterno-costal hypermobility and mobilization technique

2) spine

3) Dummy thumb on the sternal portion of the rib as close to the joint as possible. Heel of other hand placed on the dummy thumb. 

4) Apply posteriorly directed force through the heel of the mobilizing hand.

1) Costo-vertebral assesment and mobilization technique for hypomobile joint.

2) Prone

3) Dummy thumb on the rib head, neck and articular tubercle. Heel of other hand placed over the dummy thumb.

4) P/A force is put through the heel of the hand into the dummy thumb.

P/A angle of rib mobilization

1) use

2) pt. position

3) PT

4) Techniques

1) assment of rib mobility 

2) prone

3) Dummy thumb on the angle of the rib. Heel of other hand is in contact with dummy thumb applying force.

4)force directed anteriorly

Thoracic P/A Mobilization

1) use

2) pt. position

3) PT

4) Techniques

1) general technique that aid in both flexion and extension

2) prone 

3) with the pisiform in contact with the spinous process

4) progressive oscillations used with breathing

Thoracic Unilateral P/A Mobilization

1) use

2) pt. position

3) PT

4) Techniques

1) General technique that will aid in both flexion and extension.

2) prone

3)dummy hand on the transverse process of the vertebrae that needs to be mobilized. Other hand placed over the dummy thumb.

4) progressive oscillations used with breathing.

P/A Transverse process mobilization

1) use

2) pt. position

3) PT

4) Techniques

1) used to restore flexion in the thoracic spine

2) prone

3) Dummy hand: split finger one placed on each transverse process that needs to be mobilized

other hand makes contact with the dummy hand and gives a anterior force.

4) progressive oscillations or glides